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Case Presentation Peptic Ulcer DiseasePeptic Ulcer Disease

Kings County Medical CenterKings County Medical CenterHesham Ahmed, MDHesham Ahmed, MD

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History• Pt is xx yr old presented to KCHC• with hx of :• Nausea /vomiting coffee ground material

for 24 hours .• weakness , lethargic • Pt has hx of 3 visits to ER from YYYY to

2006 …main c/o weakness , n/v, weight loss, epigastric pain, constipation .

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Past medical Past medical hxhx• HTN • PARKINSON Disease • PROSTATE CA .

Medication Medication • Prevacid• Colace• Coreg• HCTZ

Social Social hxhx• Smoking and alcohol

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P.EP.E

• TEMP: 98.2• BP: 123/50• HR:81 • RR :22• Sat 97%.• ABD SOFT, LAX, MILD EPIGASTRIC

TENDERNESS, NO REBOUND, NO RIGIDITY

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LabsLabs

-CBC: 17,7,17,243-CHEM :140,4.1,105,26,34, 0.9,96

-WNL LFTS .-WNL PT,PTT .

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GI CONSULT & EGD :GI CONSULT & EGD :

• Large prepyloric 6x5cm penetrating mass seen with fresh blood clot over it .

• No active bleeding .• No bx was taken .

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SurgerySurgery

• Decision was made to take pt for surgery after medical clearance

• Billroth II and j- tube placement was done.

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PathologyPathology

• Chronic gastric ulcer with underlying granulation tissue (5.5x 4.5)cm .

• Marked submucosal edema and hemorrhage .

• Serosal edema, hemorrhage and fibrosis .

• Surface erosion and hemorrhage .

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Post op coursePost op course

• Pt was extubated and tx to ICU in stable condition .

• Post op day 6 clear liquid diet .• Post op day 7 regular diet .• Jp was d/c day 10 .• Pt was discharged home post op day

14 • Pt was seen in clinic for f/u no c/o

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ANY ANY QUESTIONS..??QUESTIONS..??

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Biography:German-Austrian surgeon(1829- 1894)Christian Albert Theodor Billrothis considered the founder of modern abdominal surgery, as well as surgeries of the stomach, bile and female genitalia. He is probably considered the most single influence on the development of modern surgical knowledge.

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Upper GI BleedingUpper GI Bleeding• Peptic ulcer is the most common cause of UGIB.• ABC.• Gastric lavage .• Endoscopy …90% diagnostic .• Hemostatic methods: thermal, injection of ethanol, epinephrine

or combination .• Permanent hemostasis is obtained in 90 % of patients. • Mortality from bleeding decreased from 10 % to 7 % over the

last 30 yrs.• Most likely related to better management with intensive care

as well as endoscopic evolution .• Repeat endoscopy ??.............yes

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DECISION MAKING ?DECISION MAKING ?

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Proton pump inhibitor Proton pump inhibitor treatment for acute peptic treatment for acute peptic

ulcer bleeding??ulcer bleeding??• OBJECTIVES: To evaluate the efficacy of PPIs in the management of

acute bleeding from PU using evidence from RCTs.

• SEARCH STRATEGY: We performed a search of CENTRAL, The Cochrane Library (Issue 3, 2003), MEDLINE (1966 to February 2003) and EMBASE (1980 to February 2003) and proceedings of recent major meetings through to February 2003. We searched the reference lists of articles and contacted pharmaceutical companies and experts in the field for additional published or unpublished data.

•• CONCLUSIONS: PPI treatment in PU bleeding CONCLUSIONS: PPI treatment in PU bleeding reduces rebleeding and surgical intervention rates in reduces rebleeding and surgical intervention rates in studies comparing treatment with placebo or H(2)RA, studies comparing treatment with placebo or H(2)RA, but there is no evidence of an effect on mortality.but there is no evidence of an effect on mortality.

• Leontiadis GI, McIntyre L, Sharma VK, Howden CW

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Role of intravenous omeprazole in patients with highRole of intravenous omeprazole in patients with high--risk peptic ulcer bleeding after successful endoscopic risk peptic ulcer bleeding after successful endoscopic

epinephrine injection: epinephrine injection:

A prospective randomized comparative trial.A prospective randomized comparative trial.METHODS: A total of 200 peptic ulcer patients with active bleeding or nonbleeding visible vessels (NBVV) who had obtained initial hemostasiswith endoscopic injection of epinephrine were randomized to receive omeprazole 40 mg infusion every 6 h, omeprazole 40 mg infusion every 12 h or cimetidine (CIM) 400 mg infusion every 12 h. Outcomes were checked at 14 days after enrollment.

CONCLUSION: A combination of endoscopic epinephrine injection and a large dose of omeprazole infusion is superior to combined endoscopicepinephrine injection with CIM infusion for preventing recurrent bleeding from peptic ulcers with active bleeding or NBVV.

Lin HJ, Lo WC, Cheng YC, Perng CL.

Division of Gastroenterology, Department of Medicine, VGH-TAIPEI, Sec. 2 Shih-Pai Road, Taipei 11217, Taiwan.

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Classification of peptic ulcerClassification of peptic ulcerBLOOD TYPE ANORMAL OR LOWLESSER CURVE TYPE I

NSAIDAny TYPE V

BLOOD TYPE OLOW HIGH ON LESSER CURVE

TYPE IV

BLOOD TYPE OHYPERACIDITYPYLORIC AND PREPYLORIC, CHANNEL ULCER

TYPE III

BLOOD TYPE OHYPERACIDITYGASTRIC & DUODENAL

TYPE II

ASSOCIATIONACIDITYLOCATION

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COMPARISONCOMPARISON

20%1%< 0.5%PCVPCV

10%5%< 1%V+PV+P

2%5-12 %<2 %V+AV+A

RECURRENCERECURRENCEMORBIDITYMORBIDITYMORTALITYMORTALITY

•C E Welch, G V Rodkey, and P von Ryll Gryska, Ann Surg. 1986 October; 204(4): 454–467.

11--A:Antrectomy, 2A:Antrectomy, 2--P:pyrolorplasty P:pyrolorplasty

33--pcv :parietal cell pcv :parietal cell vagotomyvagotomy 44--V:vagotomyV:vagotomy

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PCVV+ALOWER RE-BLEED

PCVV+PEASY

PCVV+PQUICK

WORSEBEST

11--A=A=AntrectomyAntrectomy, 2, 2--P=P=PyrolorplastyPyrolorplasty33--PCV=Parietal Cell PCV=Parietal Cell VagotomyVagotomy 44--V=V=VagotomyVagotomy

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Gastric UlcerGastric Ulcer• Unlike erosions ,gastric ulcers extend through the

muscularis mucosa and tend to occur near mucosal junctions.

• Epigastric pain 70% of patients esp. at night 30-45 %..often relieved by eating .

• Dyspepsia, nausea, vomiting, decrease in appetite in 40 -60% .

• NSAIDs :1 in 10 will develop acute ulcer .

Soll Ah path of peptic ulcer and implication for ttt .N Eng J Med 322:909-916,1990Freston JW : management of peptic ulcer :emerging issues word sur 24:250-255,2000

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Gastric UlcerGastric Ulcer• Barium study (in the absence of perforation ) are 90

% accurate in diagnosis gastric ulcer .• NOT SUBSTITUTE FOR EGD .• H.pylori in 60-90 % , the rest related to NSAIDs .• Serology sensitivity 90% /specificity 95%..cost $15

in office and $75 in lab .• Urea breath test sensitivity 95% / specificity 98 %

cost $200.• Invasive test like rapid urease assay 90%/98% .• Histology 95% /80% , Culture 99% / 100% cost for

both $150.• Gastric ulcer should be treated for 8-12 weeks then

re-evaluated for healing .• Historically , incomplete healing by 12 weeks was

almost an absolute indication for surgery .

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Gastric UlcerGastric Ulcer• Perforation carries a mortality rate of 10 to 40 %

depending on pre op shock, medical illness and perforation for more than 24 hours .

• Free air seen in 70 % of cases .• Optimal management requires excision of ulcer ,

usually best accomplished by distal gastrectomy .• In HD unstable pt excision of perforation site is

advisable with closure or 4 q bx and omentalclosure .

• Hodnett RM, Gonzalez F, LeeWC et al perf gastric u.wolrd surgery J surg 24:264-269 ,2000

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Type IType I• The most common form of gastric ulcer

55- 60% .• Optimal treatment distal gastrectomy that

includes ulcer followed by gastroduodenalanastomosis (billroth I) .

• Truncal vagotomy is not indicated .• Elective gastrectomy has mortality

2%,recurence 2% .• Proximal vagotomy with excision of the ulcer

has lower mortality ,but recurrence rates are high as 8-25 %.

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Type II, IIIType II, III• 20 -25 % of benign disease .• Treatment directed at reducing acid secretion • Vagotomy decrease peak of hydrogen ions

secretion by 50 % .• Vagotomy and antrectomy decrease peak of

hydrogen ions secretion by 85 %.• Vagotomy and antrectomy with excision of

the ulcer ….has been the treatment of the choice.

Bucker JW, Ausaustin Jc,Steinberg JB et alfx predicting failur of med ttt of G.U158:570-573,1989.

Csendes A ,Braghetto I,Smoke G:type iv gastric u. :a new hupothesis surgery 101361-366,1987.

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Type IVType IV• Uncommon in USA resection ensures lowest long

term recurrence rate • Roux-en Y esophagogastrojejunostomy (Csendes

procedure ) is recommended for ulcer with in 2 cm from GE junction.

• Radical subtotal with antecolic billroth II or roux-en Y is preferred for a malignant gastric ulcer .

Bucker JW, Ausaustin Jc,Steinberg JB et alfx predictin failur of med tttof G.U158:570-573,1989.

Csendes A ,Braghetto I,Smoke G:type iv gastric u. :a new hupothesissurgery 101361-366,1987.

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GASTRIC ULCERGASTRIC ULCER

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Mortality in patients aged over 75 years with Mortality in patients aged over 75 years with

gastrointestinal hemorrhagegastrointestinal hemorrhage..• One hundred and fifty-five patients aged 75 years

and over with gastrointestinal haemorrhage were studied and compared with a series of patients aged under 75 years.

• The mortality in patients with gastric ulcer or gastric carcinoma was not affected by age. However, the mortality in patients with duodenal ulcer was greater in the over-75s (8/31 deaths in the over-75s, 4/77 deaths in the under-75s, P = 0.01).

• There was no reluctance to operate on the over-75s.

• K Kafetz and V WijesuriyaAnn Surg. 1984 January; 199(1): 44–50.• Department of Medicine for Elderly People, Whipps Cross Hospital, Leytonstone, London.

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Emergency operations for gastric and Emergency operations for gastric and duodenal ulcers in high risk patients.duodenal ulcers in high risk patients.

• Two hundred thirty-four ulcer operations performed since 1976 were compared with 778 between 1961 and 1971.

• The hospital mortality rate has increased from 2.7 to 14.5%. Increased mortality was related to a doubling of the rate of emergency operations over age 50 and to a 94% decline in elective operations under 50.Since 1976 among 200 survivors, 20 ulcers have recurred.

CONCLUSIONS:CONCLUSIONS:• These recurrences confirm the need for vagotomy in perforated

duodenal ulcer and for resection of ulcers proximal to the duodenum.• Although most deaths occurred in this group, Such patients should

be expeditiously offered the definitive operations most appropriate to the locations of their ulcers.

• H H McGuire, Jr and J S Horsley, 3rd• Ann Surg. 1982 March; 195(3): 265–269.

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Twenty years after parietal cell Twenty years after parietal cell vagotomyvagotomy or or selective selective vagotomyvagotomy antrectomyantrectomy for treatment of for treatment of

duodenal ulcer. Final report.duodenal ulcer. Final report.• OBJECTIVE: This study was a prospective, randomized evaluation of parietal cell vagotomy (PCV) and selective vagotomy-antrectomy

(SV-A) in the treatment of duodenal ulcer.

• METHODS: • 200 patients with duodenal ulcers were randomized to PCV or SV-A. • One surgeon was responsible for the operations and follow-up

studies. • An attempt was made to evaluate all patients annually in the

hospital. Gastric analyses were performed on each visit, for which the patient gave his/her consent.

• RESULTS: • There was no operative mortality. • The recurrence rate-by-life table analysis was less (p < 0.003) after

SV-A than PCV.• Dumping was greater (p < 0.001), and there was no difference in the

frequency of diarrhea after SV-A compared with PCV.

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•• CONCLUSIONS: CONCLUSIONS: • Selective vagotomy-antrectomy and parietal cell vagotomy are

effective and safe operations, when used appropriately.• Selective vagotomy-antrectomy is preferable for patients with

pyloric and prepyloric ulcers and pyloric obstruction.

• P H Jordan, Jr and J ThornbyJ R /Soc Med. 1994 March; 87(3): 132–134.

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Duodenal ulcerDuodenal ulcer• Simple closure with Graham patch and h.pylori

eradication is associated with recurrence rate only 4.8 %, obviating the need for extensive surgery .

• Open vagotomy with antrectomy is recommended for obstruction and giant ulcer more than 2 cm .

• Gasteroenterostomy without vagotomy may be advisable in elderly patients , esp men , to avoid postop gastric atony.

• Vagotomy with pyloroplasty and oversewing..preferred for management of acute bleeding.

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DUODENAL ULCERDUODENAL ULCER

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Selective treatment of duodenal Selective treatment of duodenal ulcer with perforation.ulcer with perforation.

Sixty cases of perforation of duodenal ulcer have been treated. Nonsurgical therapy was employed without

complication in eight cases with radiologically documented spontaneous seal.

Truncal vagotomy and pyloroplasty in 36 cases and truncalvagotomy and antrectomy in two cases were each without

mortality. Four fatalities occurred among 13 cases of closure and

omental patch, each a case with severe associated disease. The mortality was 6.7% among the 60 cases; 2.4% for

chronic ulcer and 16% for acute ulcer.

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Selective treatment of duodenal Selective treatment of duodenal ulcer with perforation.ulcer with perforation.

• Selective treatment of duodenal ulcer with perforation has been based on several premises:

• 1) The natural history of the ulcer following closure of a perforation is generally favorable with an acute and unfavorable with a chronic ulcer.

• 2) An upper gastrointestinal series with water soluble contrast media can reliably document a spontaneously sealed perforation.

• 3) With a spontaneous seal, nonsurgical therapy is an acceptable option and is preferable for an acute ulcer or a chronic ulcer with poor surgical risk.

• 4) The treatment of choice for an unsealed perforation of an acute ulcer is simple surgical closure.

• 5) The treatment of choice of perforation of a chronic ulcer with acceptable surgical risk is an ulcer definitive operation.

» Ann Surg. 1986 May; 203(5): 551–557.

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A prospective study of operative risk factors in A prospective study of operative risk factors in perforated duodenal ulcers.perforated duodenal ulcers.

• Operative risk factors for patients with perforated duodenal ulcers were examined prospectively in 213 operated patients .

• Nine hospital deaths (4.2%) resulted from respiratory failure, sepsis, and bleeding. Forty-five complications developed in 27 patients (12.7%).

• Concurrent medical illness, preoperative shock, and longstandingperforations (more than 48 hours) were significant features thatincreased mortality.

• Old age, gross peritoneal soiling, and the length of the ulcer history did not affect mortality in the absence of risk factors.

• No death attributable to either sepsis or abscess formation occurred when surgery was performed within two days of perforation. Bacterial contamination may not signify clinical peritonitis during this period.

• We conclude that simple closure of perforated ulcers is a more prudent choice when any risk factor is present, but that definitive surgery in good-risk patients merits further evaluations

• Ann Surg. 1982 September; 196(3): 338–344.

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Laparoscopic Laparoscopic omentalomental patch patch repair for perforated peptic ulcer.repair for perforated peptic ulcer.

•• METHODS: From December 1992 to METHODS: From December 1992 to February 1994, laparoscopic February 1994, laparoscopic omentalomentalpatch repair followed by use of H2patch repair followed by use of H2--antagonists was performed antagonists was performed successfully in 11 patients. Fiftysuccessfully in 11 patients. Fifty--five five patients underwent other surgical patients underwent other surgical procedures for perforated peptic ulcers procedures for perforated peptic ulcers (conventional open (conventional open omentalomental patch: 4, patch: 4, selective selective vagotomyvagotomy in combination with in combination with antrectomyantrectomy: 24, distal : 24, distal gastrectomygastrectomy: : 27). 27).

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RESULTS:RESULTS:•• The average operation time was 135 The average operation time was 135

minutes. Administration of minutes. Administration of postoperative pain medication was postoperative pain medication was reduced remarkably (0.9 times per reduced remarkably (0.9 times per patient), and all patients recovered patient), and all patients recovered rapidly. No serious postoperative rapidly. No serious postoperative complications were recorded. After a complications were recorded. After a mean period of 11 months, the mean period of 11 months, the postoperative evaluation was postoperative evaluation was satisfactory for all patients, and no satisfactory for all patients, and no ulcer recurrence was found. ulcer recurrence was found.

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CONCLUSIONS:CONCLUSIONS:•• In perforated peptic ulcer disease, laparoscopic In perforated peptic ulcer disease, laparoscopic

omentalomental patch repair offers a number of patch repair offers a number of advantages. Because no upper abdominal advantages. Because no upper abdominal incision is made, there is decreased incision is made, there is decreased postoperative pain, and the patient rapidly postoperative pain, and the patient rapidly recovers with fewer and less severe recovers with fewer and less severe complications. Although the procedure requires complications. Although the procedure requires a surgeon with particular expertise in a surgeon with particular expertise in endoscopicendoscopic suturing technique, surgeons suturing technique, surgeons familiar with laparoscopic familiar with laparoscopic cholecystectomycholecystectomy can can readily perform it after some practice. readily perform it after some practice.

•• M Matsuda, M M Matsuda, M NishiyamaNishiyama, T , T HanaiHanai, S Saeki, and T Watanabe, S Saeki, and T Watanabe

•• Department of Surgery, Chukyo Hospital, Nagoya, Japan./Department of Surgery, Chukyo Hospital, Nagoya, Japan./Ann Surg. 1995 March; 221(3): 236–240.

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ConclusionConclusionLessons from history•• Diseases which we have previously considered Diseases which we have previously considered

to be unchanging are, in fact, evolving in to be unchanging are, in fact, evolving in epidemiology, diagnosis, and management.epidemiology, diagnosis, and management.

•• The attributes which lead to the wide adoption The attributes which lead to the wide adoption of one operative procedure but not another are of one operative procedure but not another are not clear. The decision making process should not clear. The decision making process should be directed toward the specific problem that be directed toward the specific problem that resulted from the peptic ulcer and pt condition.resulted from the peptic ulcer and pt condition.